

<div class="row">
			<div  class="title">
				<div class="t1"><label class="lb3">今回ご購入頂いた商品をお選びください。<br>（複数選択可）</label></div>
				<div class="t2"><img class ="td-icon" src="<?php echo base_url(); ?>assets/image/title2.png" ></div>
			</div>
			<!--<label class="desc" id="title1" for="Field1">応募ID(14ケタ)<img src="assets/image/2_PC_キムタオル_入力_03.png" width="20" height="10"></img></label>-->
			<div class="fieldColumn" >
				<table>
					<tbody>
							<tr>
								<td width="50%"><input type="checkbox" name="q1[]" id="i_buyNameItem1" class="i_buyNameItem" value="7"><label for="i_buyNameItem1">キムタオル4つ折り(茶色)</label></td>
								<td width="50%"><input type="checkbox" name="q1[]" id="i_buyNameItem2" class="i_buyNameItem" value="8"><label for="i_buyNameItem2">キムタオルホワイト 4つ折り</label></td>
							</tr>
							<tr>
								<td><input type="checkbox" name="q1[]" id="i_buyNameItem3" class="i_buyNameItem" value="1"><label for="i_buyNameItem3">キムワイプS-200</label></td>
								<td><input type="checkbox" name="q1[]" id="i_buyNameItem4" class="i_buyNameItem" value="2"><label for="i_buyNameItem4">キムワイプM-150</label></td>
							</tr>
							<tr>
								<td><input type="checkbox" name="q1[]" id="i_buyNameItem5" class="i_buyNameItem" value="3"><label for="i_buyNameItem5">キムワイプL-100</label></td>
								<td><input type="checkbox" name="q1[]" id="i_buyNameItem6" class="i_buyNameItem" value="4"><label for="i_buyNameItem6">JKワイパー150-S</label></td>
							</tr>
							<tr>
								<td><input type="checkbox" name="q1[]" id="i_buyNameItem7" class="i_buyNameItem" value="5"><label for="i_buyNameItem7">JKワイパー100-S</label></td>
								<td><input type="checkbox" name="q1[]" id="i_buyNameItem8" class="i_buyNameItem" value="6"><label for="i_buyNameItem8">ケイドライ132-S</label></td>
							</tr>
					</tbody>
				</table>
					
					
					
					
					
					
					
					
			</div>
</div>
<div class="row">
			<div  class="title">
			
				<div class="t1"><label class="lb3">月間購入量(全8商品合計)をお選びください。</label></div>
				<div class="t2"><img class ="td-icon" src="<?php echo base_url(); ?>assets/image/title2.png" ></div>
			</div>
			<!--<label class="desc" id="title1" for="Field1">応募ID(14ケタ)<img src="assets/image/2_PC_キムタオル_入力_03.png" width="20" height="10"></img></label>-->
			<div class="fieldColumn" >
					<table>
					<tbody>
							<tr>
								<td width="50%"><input type="radio" name="q2[]" id="i_buyQuantity1" class="i_buyNameItem" value="1"><label for="i_buyQuantity1">１～２ケース</label></td>
								<td width="50%"><input type="radio" name="q2[]" id="i_buyQuantity2" class="i_buyNameItem" value="2"><label for="i_buyQuantity2">３～４ケース</label></td>
							</tr>
							<tr>
								<td><input type="radio" name="q2[]" id="i_buyQuantity3" class="i_buyNameItem" value="3"><label for="i_buyQuantity3">５～９ケース</label></td>
								<td>	<input type="radio" name="q2[]" id="i_buyQuantity4" class="i_buyNameItem" value="4"><label for="i_buyQuantity4">１０～２９ケース</label></td>
							</tr>
							<tr>
								<td colspan="2"><input type="radio" name="q2[]" id="i_buyQuantity5" class="i_buyNameItem" value="5"><label for="i_buyQuantity5">３０ケース以上</label></td>	
							</tr>
					</tbody>
				</table>
			</div>
</div>
<div class="row">
			<div  class="title">
				<table>
					<tbody>
						<tr>
							<th style="font-weight:900; font-style:bold;padding:10px;"><label class="lb3">業種をお教えください。</label></th>
								<th width="50"><img class ="td-icon" src="<?php echo base_url(); ?>assets/image/title2.png" ></th>
						</tr>
					</tbody>
				</table>
				
			</div>
			<!--<label class="desc" id="title1" for="Field1">応募ID(14ケタ)<img src="assets/image/2_PC_キムタオル_入力_03.png" width="20" height="10"></img></label>-->
			<div class="fieldColumn" >
					<table>
					<tbody>
							<tr>
								<td width="50%"><input type="checkbox" name="q32[]" id="i_workType3_1" class="i_buyNameItem" value="1"><label for="i_workType3_1">一般工場</label></td>
								<td width="50%"><input type="checkbox" name="q32[]" id="i_workType3_2" class="i_buyNameItem" value="2"><label for="i_workType3_2">印刷</label></td>
							</tr>
							<tr>
								<td><input type="checkbox" name="q32[]" id="i_workType3_3" class="i_buyNameItem" value="3"><label for="i_workType3_3">食品</label></td>
								<td>	<input type="checkbox" name="q32[]" id="i_workType3_4" class="i_buyNameItem" value="4"><label for="i_workType3_4">医薬品</label></td>
							</tr>
							<tr>
								<td><input type="checkbox" name="q32[]" id="i_workType3_5" class="i_buyNameItem" value="5"><label for="i_workType3_5">化粧品</label></td>
								<td><input type="checkbox" name="q32[]" id="i_workType3_6" class="i_buyNameItem" value="6"><label for="i_workType3_6">電気精密</label></td>
							</tr>
							<tr>
								<td><input type="checkbox" name="q32[]" id="i_workType3_7" class="i_buyNameItem" value="7"><label for="i_workType3_7">メンテナンス</label></td>
								<td><input type="checkbox" name="q32[]" id="i_workType3_8" class="i_buyNameItem" value="8"><label for="i_workType3_8">病院</label></td>
							</tr>
							
							<tr>
								<td><input type="checkbox" name="q32[]" id="i_workType3_9" class="i_buyNameItem" value="9"><label for="i_workType3_9">介護</label></td>
								<td><input type="checkbox" name="q32[]" id="i_workType3_10" class="i_buyNameItem" value="10"><label for="i_workType3_10">車両整備</label></td>
							</tr>
							<tr>
								<td><input type="checkbox" name="q32[]" id="i_workType3_11" class="i_buyNameItem" value="11"><label for="i_workType3_11">塗装</label></td>
								<td>	<input type="checkbox" name="q32[]" id="i_workType3_12" class="i_buyNameItem" value="12"><label for="i_workType3_12">研究機関</label></td>
							</tr>
							<tr>
								<td><input type="checkbox" name="q32[]" id="i_workType3_13" class="i_buyNameItem" value="13"><label for="i_workType3_13">学校</label></td>
                                                                <td><input type="checkbox" name="q32[]" id="i_workType3_14" class="i_buyNameItem" value="99"><label for="i_workType3_14">その他</label><input type="text" name="q32text" class="type8" value="" id="q32text"></td>
							</tr>
					</tbody>
				</table>
			</div>
</div>
<div class="row">
			<div  class="title">

				<div class="t1"><label class="lb3">キムタオルの使用用途をお教えください。</label></div>
				<div class="t2"><img class ="td-icon" src="<?php echo base_url(); ?>assets/image/title2.png" ></div>
			</div>
			<!--<label class="desc" id="title1" for="Field1">応募ID(14ケタ)<img src="assets/image/2_PC_キムタオル_入力_03.png.png.png.png" width="20" height="10"></img></label>-->
			<div class="fieldColumn" >
			<table>
				<tbody>
					<tr>
							<td  style="padding-left:5px;" width="50%"><input type="checkbox" name="q5[]" id="id1" class="i_buyNameItem" value="1"><label for="id1">汚れの拭き取り</lable></td>
							<td>&nbsp;</td>
					</tr>
					<tr>
							<td colspan="2">(<input type="checkbox" name="q42[]" id="id11" class="i_buyNameItem" value="1"><label for="id11">油</label>
					<input type="checkbox" name="q42[]" id="id12" class="i_buyNameItem" value="2"><label for="id12">薬液</label>
					<input type="checkbox" name="q42[]" id="id13" class="i_buyNameItem" value="3"><label for="id13">インク</label>
					<input type="checkbox" name="q42[]" id="id14" class="i_buyNameItem" value="4"><label for="id14">塗料</label>
					<input type="checkbox" name="q42[]" id="id15" class="i_buyNameItem" value="99"><label for="id15">その他</label><input type="text" class="type4" name="q42text" value="" id="q42text" size="8">)</td>
					</tr>
					
					<tr>
								<td style="padding-left:5px;" ><input type="checkbox" name="q5[]" id="id2" class="i_buyNameItem" value="2"><label for="id2">脱脂洗浄</label></td>
								<td  ><input type="checkbox" name="q5[]" id="id3" class="i_buyNameItem" value="4"><label for="id3">除菌・消毒清掃</label></td>
					</tr>
					<tr>
								<td style="padding-left:5px;" ><input type="checkbox" name="q5[]" id="id4" class="i_buyNameItem" value="5"><label for="id4">敷きもの用途</label></td>
								<td><input type="checkbox" name="q5[]" id="id5" class="i_buyNameItem" value="5"><label for="id5">包む用途</label></td>
					</tr>
					<tr>
								<td style="padding-left:5px;" ><input type="checkbox" name="q5[]" id="id6" class="i_buyNameItem" value="99"><label for="id6">その他</label><input type="text" class="type8" name="q5text" value="" id="q5text"></td>
								
					</tr>
				</tbody>
			</table>
					
			</div>
</div>
<div class="row">
			<div  class="title">
				<table>
					<tbody>
						<tr>
							<th style="font-weight:900; font-style:bold;padding:10px;"><label class="lb3">キムタオルの使用方法。</label></th>
								<th width="50"><img class ="td-icon" src="<?php echo base_url(); ?>assets/image/title2.png" ></th>
						</tr>
					</tbody>
				</table>
			</div>
			<!--<label class="desc" id="title1" for="Field1">応募ID(14ケタ)<img src="assets/image/2_PC_キムタオル_入力_03.png.png.png.png" width="20" height="10"></img></label>-->
			<div class="fieldColumn" >
					<table>
						<tbody>
								<tr>
									<td colspan="2"><input type="radio" name="q6[]" id="i_workType_1" class="i_workType" value="1"><label for="i_workType_1">乾いた状態</label> 
												<input type="radio" name="q6[]" id="i_workType_2" class="i_workType" value="2"><label for="i_workType_2">濡らした状態</label> 	<br>
										&nbsp;濡らす場合は濡らす液体を教えてください。</td>
								</tr>
								<tr>
										<td style="padding-left:5px;"><input type="checkbox" name="q7[]" id="i_workType7_1" class="i_buyNameItem" value="1"><label for="i_workType7_1">水</label></td>
										<td>	<input type="checkbox" name="q7[]" id="i_workType7_2" class="i_buyNameItem" value="2"><label for="i_workType7_2">アルコール</label></td>
								</tr>
								<tr>
										<td style="padding-left:5px;"><input type="checkbox" name="q7[]" id="i_workType7_3" class="i_buyNameItem" value="3"><label for="i_workType7_3">溶剤</label></td>
										<td><input type="checkbox" name="q7[]" id="i_workType7_4" class="i_buyNameItem" value="99"><label for="i_workType7_4">その他</label>
										<input type="text" name="q7text" class="type8" value="" id="q7text"></td>
								</tr>
								
						</tbody>
					</table>
					
				
					
					
			</div>
</div>
<div class="row">
			<div  class="title">
				<table>
					<tbody>
						<tr>
							<th style="font-weight:900; font-style:bold;padding:10px;"><label class="lb3">布ウエスを使用していますか。<label></th>
								<th width="50"><img class ="td-icon" src="<?php echo base_url(); ?>assets/image/title2.png" ></th>
						</tr>
					</tbody>
				</table>
			</div>
			<!--<label class="desc" id="title1" for="Field1">応募ID(14ケタ)<img src="assets/image/2_PC_キムタオル_入力_03.png.png.png.png" width="20" height="10"></img></label>-->
			<div class="fieldColumn" >
			<table>
				<tbody>
					<tr>

						

						<td colspan="2"><input type="radio" name="q8[]" id="1" class="i_workType" value="1"><label for="1">使用している</label> 
						<input type="radio" name="q8[]" id="2" class="i_workType" value="2"><label for="2">使用していない</label> <br>

						&nbsp;使用しているとお答えいただいた方へご質問です。<br />
						&nbsp;どのような種類のウエスを使用していますか。</td>
					</tr>
					<tr>

						

						<td style="padding-left:5px;"><input type="checkbox" name="q9[]" id="i_workType9_1" class="i_buyNameItem" value="1"><label for="i_workType9_1">メリヤスウエス</td>
						<td><input type="checkbox" name="q9[]" id="i_workType9_2" class="i_buyNameItem" value="2"><label for="i_workType9_2">白ウエス</td>

					</tr>
					<tr>

						

						<td style="padding-left:5px;"><input type="checkbox" name="q9[]" id="i_workType9_3" class="i_buyNameItem" value="3"><label for="i_workType9_3">タオルウエス</td>
						<td><input type="checkbox" name="q9[]" id="i_workType9_4" class="i_buyNameItem" value="4"><label for="i_workType9_4">色メリヤスウエス</td>

					</tr>
					<tr>

						

						<td style="padding-left:5px;"><input type="checkbox" name="q9[]" id="i_workType9_5" class="i_buyNameItem" value="5"><label for="i_workType9_5">色・シマウエス</td>
						<td><input type="checkbox" name="q9[]" id="i_workType9_6" class="i_buyNameItem" value="6"><label for="i_workType9_6">レンタルウエス</td>

					</tr>
					<tr>

						

						<td style="padding-left:5px;"><input type="checkbox" name="q9[]" id="i_workType9_7" class="i_buyNameItem" value="99"><label for="i_workType9_7">その他</label><input type="text" name="q9text" class="type8" value="" id="q9text"></td>
						<td> </td>
					</tr>
				</tbody>
			</table>

			</div>
</div>

